At the beginning of the Second World War the technique of primary wound treatment laid down during the 1914–18 War, and continued in the treatment of civilian injuries afterwards, was carried out by the army surgeons. After the surgical cleansing of the wound the closed plaster treatment as developed during the Spanish Civil War was utilised. Very soon the sulphonamides were employed as bacteriostatics, both locally to the wound and parenterally by the mouth and later intravenously and intra-abdominally.

The antibiotic penicillin, when introduced in the later half of 1943, gradually displaced the sulphonamides and with its help the regular delayed primary suture of wounds was introduced. The primary efficient surgical treatment of the wound remained, however, the essential element in wound treatment.

It is necessary to survey the nature of the wounds produced by the different missiles, and the special problems involved in injuries to different parts of the body, before proceeding to discuss the development of wound treatment during the war in some detail, both in regard to the various aspects and also as a chronological account of the conditions present in the different campaigns in which the 2 NZEF fought.

There was a marked difference in the type and severity of the wounds produced by shells, mines, and bullets. Very severe wounds, often multiple, were often caused by shells, mortars, mines, grenades, and booby traps. Unless it struck bone, the rifle bullet was generally less severe in its effect. Fortunately, shell splinters more often caused numerous small wounds rather than severe wounds. Mine wounds were particularly severe and multiple, frequently involving the face as well as destroying the feet.

The nature of the wound varied a good deal according to the region of the body involved, and especially as to the amount of muscular tissue present.

In the head the penetration of the skull and involvement of the brain called for special equipment, and treatment by personnel trained in neurosurgery. Injuries to the face, apart from the involvement of the eyes, were of importance with regard to the prevention of disfigurement and the associated fracture of the jaw. The neck injuries were often associated with injuries to the large vessels and to the larynx and trachea. Wounds of the thorax were often associated with lethal injuries to the heart and blood vessels, and the sucking wounds presented symptoms demanding immediate relief. The accumulation of blood in the pleural cavity not only interfered with respiration, but also acted as a nidus for infection.

The abdominal wounds were of special importance because of the injuries to the viscera, particularly the hollow viscera, but bleeding in the retro-peritoneal tissues and muscle injury were also of importance.

The buttock and perineum were dangerous areas because of the liability to abdominal, especially to rectal, injuries, and also because of the mass of muscle tissue particularly liable to anaerobic infection.

As regards the limbs, where the bulk of the uncomplicated wounds occurred, the thighs and calves with the bulk of muscle were again prone to serious infection; and vascular injuries were of special importance, especially in the thighs, because of the danger of gangrene.

Injury to bone and joint produced added risk of sepsis and prolonged disability.

Injuries of the larger nerves, though of no importance as regards wound healing, led to the longest period of disability and demanded prolonged treatment.

Traumatic amputation of the limb produced by gross injury proved to be of considerable importance because of the profound and continued shock associated with the extensive tissue damage.

The depth and the extent of the wound naturally varied enormously in degree from a small abrasion to a devastating tissue destruction, and from a perforating wound with two small perforations of the skin, with no swelling of the limb, to a large blowout of skin and muscle leaving a huge hole in a limb or, as commonly occurred, in the buttock.

In uncomplicated wounds the depth and the extent were important factors, but the amount of muscle involvement was of cardinal importance as it was in damaged muscle that infection, especially dangerous anaerobic infection, was especially prone to occur.

In addition to the missile itself producing in the wound damaged non-vital tissue, there was introduced into the wound foreign bodies of different kinds including dirt, clothing, and portions of the missile itself, all of which acted as irritants to the tissues and potential foci of infection.

The treatment of the wound had to be such as to take all these factors into consideration.

Before the wound could be dealt with it was necessary to remove any overlying clothing and expose the wound itself and a considerable area around, generally the whole limb in a limb injury, and sometimes the whole body. This exposure was necessitated not only to enable the wound to be adequately treated, but also to ensure that no other wounds were present. Exposure of one area at a time was generally necessary because of the shocked condition of the patient. (The methods of prior resuscitation will be described later.) The skin around the wound was then thoroughly cleansed over a very wide area by soap and hot water and shaved when any hair was present, also shaving a limb on which plaster extension was to be applied. The limb was then dried and painted with iodine solution or other skin antiseptic, and guards adjusted. In ordinary wound operations mackintosh guards were generally utilised in the forward areas so as to save washing.

The surgical cleansing of the wound was then proceeded with according, to a great extent, to the interval that had elapsed since wounding.

Except in the case of wounds operated on very late, and in septic wounds, the thinnest possible slice was taken off the cut surfaces of the skin, and the wound freely enlarged longitudinally so as to open up thoroughly the deeper parts of the wounds. The deep fascia was opened up in the same way and, if necessary, also the muscle planes.

All seriously traumatised tissue was now removed from the internal wound surface either by knife or scissors. Special attention was given to muscles, all avascular discoloured muscle being removed so that a fresh bleeding surface was presented. Tags of fascia and damaged subcutaneous tissue were removed, and all foreign tissue such as dirt and clothing were removed by instruments, wiping, and washing. All bleeding was stopped, the suction apparatus being of great value in the catching of the bleeding points and also in removing blood and clot from the wound. Blood vessels and nerves were preserved, as was bone. The extent of the removal of tissue would depend on the amount of tissue damage and partly on the interval since wounding.

At first in North Africa the removal of skin was excessive, so much so at times as to interfere with the subsequent healing of the wound. It was then stressed that skin was a very vital tissue which was seldom the site of infection, and excessive removal was discontinued.

The extent of removal of tissue in the deeper parts of the wound also varied during the different periods. This was especially so when the scene changed from the relatively non-infective terrain of North Africa to Italy, where more severe wound infection was noted and more radical wound toilet was called for.

Great tension in the wound was found at times, especially in the thigh and sometimes in the calf. This was relieved by free incision in skin and especially in the deep fascia, which was, if necessary, divided transversely.

After all the wound had been cleansed, tension relieved, bleeding dealt with and the wound surface dried, the whole surface was lightly covered with powder, at first sulphanilamide and later penicillin in a sulphanilamide base.

Gauze dressings were then applied so as to keep the wound open without plugging. At first sterile vaseline gauze or tulle gras was used so as to ensure an atraumatic dressing, which would not produce pain and trauma on redressing. In Italy, when delayed primary suture became the routine, plain gauze was substituted for the vaseline gauze as it was found that this dressing left a healthier surface for suture, and as the gauze was removed under the anaesthetic the question of pain did not arise. Cotton wool, gamgee, etc., were used as outer dressings.

In all fracture cases and in all large limb wounds splints were applied, in the great majority of cases of plaster, or with plaster incorporated with a Thomas or Kramer splint.

Foreign bodies were removed if located during the process of wound cleansing, or if their position was known and the foreign body was large enough to warrant the exploration. It was seldom that X-rays were taken for this purpose, and in the Field Ambulances X-ray was not available. Hunting for foreign bodies in the seriously shocked cases was in general not warranted, especially if this entailed the opening up of fresh tissue planes. It was recognised, however, that the removal of foreign bodies was desirable, and a much larger proportion were removed during the latter part of the war. The smooth bullet was less prone to produce sepsis than the jagged pieces of shell which often introduced clothing.

The wound, as already stated, was always left wide open and kept open by a gauze dressing, and this ensured some wound drainage. In large wounds of the thigh and often of the calf dependent drainage was generally instituted by making incision in the back of the limb, especially in the earlier period of the war. and before penicillin became available. When sepsis developed, free drainage was provided by large incisions.

At the beginning of the war the closed plaster technique was adopted practically universally and all limb wounds were treated in this way. The wound treatment as described was employed for all large wounds. Vaselined gauze was then applied to the cleansed and enlarged wound and the limb enclosed in plaster. The results were very good. The patients travelled comfortably. The temperature tended to subside satisfactorily, and little toxaemia was present in the majority of the cases. There was little strain on the staffs of the hospitals as dressings were infrequent.

Certain disadvantages were evident, and these became more obvious as time went on, but the treatment had obtained such a grip on the imagination of the medical officers that the disadvantages were prone to be overlooked, especially in those who had had no previous experience of war wounds. The first disadvantage noted was that there was a grave danger of interfering with the blood supply of the limb if a closed plaster was applied, without padding, shortly after wounding. Some limbs were lost because of this. Instructions were then issued by Army that padding should always be used for the primary plaster, and that the plaster should also be split before the case was transferred to another unit.

The second disadvantage was that the plasters became very stained by the secretion from the wound, and also very offensive. Much ingenuity was displayed to obviate this, and carbon dressings and deodorants applied, but without much success.

The most important disadvantage, however, was the long period generally required to promote healing, with the resultant serious wasting of the limb and loss of functional activity. This was naturally noticed only as time went on. It was also noted that secondary infections arose, notably by B. Pyocyaneus. Finally it was agreed that the principle of primary immobilisation of the wounded limb was sound, but that, after the first ten days, further complete immobilisation was unnecessary and undesirable in the majority of the non-fracture cases, and that more rapid healing and return of function should be aimed at. Changes were soon made in attempts to clean up the wounds more rapidly and close them by secondary suture. Many methods were utilised, including the Carrel-Dakin method, but generally simple dressings with acriflavine and other antiseptics were used. Comparatively little was done in 2 NZEF, however, as our policy of evacuating the seriously wounded to New Zealand as soon as a hospital ship was available removed the patients from our hospitals in the Middle East before their wounds were ready for suture. This was contrary to what occurred during the First World War, when it was the routine procedure to hold cases in England till after the wounds had been sutured and healed. The closed plaster technique, however, continued to be utilised throughout the war in the treatment of below-knee fractures till delayed primary suture of wounds was carried out in all suitable cases, the plaster splint being reapplied after suture. The same applied generally to the treatment of arm fractures.

The discovery of penicillin and its use in the treatment of war wounds produced a revolutionary change and stimulated the surgeons to carry out the early suture of wounds, which, with the control of infection by penicillin, led to a marked improvement in wound healing and a marked diminution in hospitalisation. The first experience of 2 NZEF with the new antibiotic was in Cairo, where Pulvertaft of 15 Scottish Hospital produced some penicillin and made a small supply available to our hospitals for the treatment of special cases.

Then in August 1943 there was held at Tripoli an epoch-making conference, when Professor Florey and Brigadier Cairns came out from England to superintend experiments and evaluate the results of penicillin treatment of wounded from the Sicilian campaign.

Professor Florey described the following results of his experiments at Oxford:

Penicillin had been introduced through small tubes in the wound every 8 hours for 4–5 days. It had been found that there was consistent eradication of the streptococcus and staphylococcus, but no effect on the gram negative bacilli, such as the pyocyaneus and B. Coli. The wounds had healed well in spite of continuing gram-negative infection. Osteomyelitis had been cured by large doses of intravenous penicillin.

Professor Florey drew attention to the presence of resistant strains of staphylococci, and also to the fact that bacteria can become artificially resistant following administration of penicillin, so that adequate dosage should be given at once as was done in the case of the sulphonamides. He stated that fractures with longstanding infection had not been improved by penicillin.

The experimental treatment of the wounded from Sicily was carried out in two British hospitals and 3 NZ General Hospital in the Tripoli area. For the experiments penicillin was available as a calcium salt for local application, and as a sodium salt for parenteral use. The calcium salt was mixed with sulphanilamide to secure a penicillin content of three strengths—5000 units, 2000 units, and 500 units per gramme. The 5000-unit strength was used in a small number of cases when a single application was given prior to suture without tubes, while the 2000-unit strength was used as the routine wound application, and the 500 strength was prepared for use as a daily surface application for burns. It was also prepared in a solution of 250 units per cubic centimetre which was instilled into the wound through tubes, at first eight-hourly and later twice daily, the standard total dosage advised being 50,000 units.

The sodium salt was made into a solution containing 5000 units per cubic centimetre, and 500,000 units was given in doses of 15,000 units, intramuscularly or intravenously every three hours, for wounds with associated fracture of the long bones.

In a series of 171 soft-tissue wounds from Sicily most cases healed well with early closure and the use of penicillin, in spite of the presence of gram-negative pus. Some cases had wound toilet in Sicily; others arrived in North Africa without treatment and then the wounds were excised. At Sousse and Tripoli most wounds were sutured after the application of penicillin powder and then irrigated with penicillin solution introduced through small tubes into the wounds for some days afterwards.

Fracture cases were dealt with in several different ways. The majority were given primary surgical treatment in Sicily; in a few cases penicillin was applied locally to the wound, but most had no penicillin. The cases were all sutured after arrival at Tripoli when the condition of the wound permitted mechanical closure, penicillin being applied locally. Parenteral penicillin was then given either intramuscularly or intravenously in dosages of 400,000 to 500,000 units over five days.

In the early cases some of the wounds were closed under considerable tension and the wounds broke down. Later the centre of the wound was left open whenever tension was great or a dead space was unavoidable. Constant inspection of the wounds was found to lead to fresh infection. Of the main group of twenty-three cases, twelve were wholly successful, five partially so, and six were failures, with one amputation. The humerus cases were more successful than the femurs.

Altogether the results were not such as to warrant the adoption of primary suture of fractures, or immediate suture on arrival at Base Hospital without previous penicillin treatment. Some very septic cases were observed, and drainage was necessary in the majority of cases. The results showed, however, that in the majority of cases infection had been satisfactorily controlled, and that with a larger amount of penicillin administered parenterally over a longer period better results could be hoped for.

Cultures taken from the wounds in Sicily showed infection by staphylococci in 23 per cent, haemolytic streptococci in 47 per cent, and claustridia in 30 per cent. Welchii was the predominant anaerobic organism.

Cultures taken at different periods from the wounds investigated in Tripoli showed that staphylococcus aureus was present in 53 per cent of the wounds, and streptococcus haemolyticus in 12 per cent. The streptococci were nearly always associated with staphylo-cocci. It was the exception for the wound to be free of cocci, though it might not be clinically septic. After wound treatment with penicillin the gram-positive organisms were got rid of in seven days, sometimes in two to three days. Pyocyaneus was very common, and its lack of pathogenity was doubted by the bacteriologist. Resistant strains of staphylococci, but not of streptococci, were encountered. In the cases of chronic infection seen at Algiers the organisms were nearly all streptococci.

In subsequent discussion Professor Florey summed up the opinion of the conference by stating that whereas the results in the treatment of simple flesh wounds had been satisfactory on the whole a larger dosage of penicillin intramuscularly over a longer period was necessary in the treatment of fractures, for which he suggested partial suture of the wound with drainage. The Consultant Surgeon MEF, Major-General Ogilvie, counselled concentration on the fracture cases as long as penicillin was in short supply. It was noted generally that gram-negative infections, especially of the pyocyaneus, were commonly present when the gram-positive organisms had been largely eliminated by penicillin. Profuse discharge was often noted, but there were no general ill-effects and no marked interference with the healing of the wound. Penicillin, besides preventing and dampening down acute infection, had produced a feeling of better health.

For the treatment of fractures it was recommended that sodium penicillin should be given continuously for a minimum of five days, either by three-hourly intramuscular injections or in continuous glucose saline drip infusion. The five-day course, totalling 500,000 units, was considered sufficient for fractures of the upper extremity, but for fractures of the femur and tibia a course lasting seven to ten days (700,000 to 1,000,000 units) was advised. These figures referred to severe comminuted fractures. An incomplete facture, or a fracture in other than the long bones, did not usually require more than 300,000 units, and calcium penicillin applied locally sometimes sufficed. Looking back it was clear that the length of the course (five days) for the experiments had been too arbitrarily fixed and was not related closely enough to the severity of the fracture. (Later in the war it became the custom to give much longer courses for the severe cases.)

The Consultant Surgeon 2 NZEF suggested at the conference that the better technique might be the delayed suture of wounds, following wound and intramuscular injection with penicillin, the wounds having previously been excised. Certain wounds, such as the large buttock wound, where severe infection from contamination would almost certainly follow if the wound were left open, might be primarily sutured and tubes for instillation of penicillin inserted. When tension was great, suturing was not advisable, especially in the lower third of the leg. Deep retained stitches could be obviated by employing a figure-of-eight stitch, and fairly thick silk drawn through sulphonamide paste might be used instead of silkworm gut; and stitches were better if not close together. The sooner a wound was closed the better, as infection was inevitable in every open wound. Fracture cases did not seem to be suitable for primary suture, but penicillin powder and penicillin fluid could be used to clean the wound for possible early secondary suture. In penicillin there was a powerful method of eradicating gram-positive organisms. With an adequate supply and improved technique a marked advance in the treatment of war wounds was likely to eventuate.

The New Zealand Medical Corps had been privileged to take part in these important and historical investigations and in the conference itself, and this, fortunately, made our Corps penicillin-minded and eager to adopt the new line of treatment. A complete resume was written by the Consultant Surgeon and sent to all our units, with full details of suggested forms of treatment.

Further trials with penicillin were carried out in Italy. Lieutenant-Colonel J. S. Jeffrey, who was Surgical Divisional Officer in the main British hospital in Tripoli, had been appointed to superintend the supply and application of penicillin, and, as both our CCS and 3 NZ General Hospital had first-hand knowledge of the experiments in Tripoli, our hospitals were utilised in the further experiments.

From December 1943 the method employed in the wound treatment by penicillin was:

The story of the development of the Blood Transfusion Service is given elsewhere, but it is necessary to stress the great importance of blood, plasma, and serum in the resuscitation of the wounded man and in wound repair.

There was a very severe loss of blood in many large wounds, especially of the limb. Lieutenant-Colonel Grant, RAMC, estimated that a loss of 50 per cent of the total blood volume was common in such injuries, so that up to five pints of blood was required to make up the loss.

At first the use of blood was confined to the primary treatment of the severely wounded man, in order to replace blood loss and so sustain the general circulation and combat shock. This led to the direct saving of many lives and enabled operative treatment to be safely undertaken. Later, blood was used at the base hospitals to combat the Secondary anaemia which was almost invariably present, often to a marked degree, in patients with severely infected wounds. Often haemoglobin was down to 50 per cent or less, and the red cells to 3,000,000 or under in these cases. As much as three pints of blood was often required to bring the haemoglobin and red cells up to a satisfactory level. Fresh blood carefully cross-typed had to be used and given slowly, as severe reactions were common, especially in those cases who had already been transfused in the forward areas.

As the war progressed it was realised that a marked protein deficiency was present in all severe casualties, and that blood plasma or serum transfusions were of great value in counteracting it. It was realised that biochemical changes had a very great effect on wound infection and healing. During the latter half of the war, not only protein deficiency but deficiency of chemicals and vitamins were recognised as being of the utmost importance. It was recognised that the wound healing depended on the general metabolism of the body and that adequate food, particularly those foods of high protein content, and adequate fluid were necessary, especially in the presence of infection.

Plasma and serum were of particular value in all cases of protein deficiency and were generally given as a daily routine in the early stages of the most serious cases.

The evacuation of wounded men from the forward areas shortly after or without operation was found to interfere seriously with wound healing. This was especially marked following transport over the roadless desert, but even on good road surfaces ambulance transport was harmful, and swelling of the limb often occurred. If primary suture had been undertaken, this swelling led to tension and tearing of the stitches. Plaster splints caused dangerous constriction of the swollen limb, and this led to the padding and splitting up of the splints in the forward areas.

At the beginning of the war, when the closed plaster treatment was carried out for all the large wounds, the original plaster with its underlying vaseline gauze dressing remained untouched for a period generally of two to three weeks. The plaster was then removed and the dressing and plaster changed, still using vaseline gauze unless frank sepsis called for different treatment. When sulphanilamide was adopted as an application to the surface of the wound it was reapplied when the original plaster dressing was removed. Later it was ascertained that the local application of sulphonamides to the wound often led to the patient becoming sensitised to sulphonamide, and also that the sulphonamide locally had little effect on ingrained infection. In consequence, the local application of the sulphonamides was discontinued, reliance being placed on the administration of sulphonamides by mouth for the first five to seven days after wounding, and later for the treatment of sulphonamide-sensitive infections such as that due to the streptococcus, with strictly regulated dosage for a limited period.

During this period, if definite sepsis arose it was countered by methods of treatment for infection as ordinarily applied in the pre-sulphonamide period. Drainage has been mentioned, and associated with that was the free opening up of the infected area by incision and the removal of any slough or gangrenous or avascular muscle, as well as the evacuation of any collection of pus. Treatment was instituted by antiseptic lotions such as the electrolytic hypochlorites, which were often instilled into the wound following the methods of the First World War. Acriflavine was also used, as was dichloramine T. Saline baths were sometimes used.

When penicillin was available it was applied locally in a sulphanilamide base at the original treatment of the wound, and thereafter was applied locally by instillation into the wound, and in addition it was given parenterally. For infection which was resistant to penicillin the older methods of treatment were again resorted to. The treatment of established sepsis depended on the type of infection and on the organisms responsible.

The most common organisms found in the septic wounds were the gram-positive streptococci and staphylococci. The gram-negative organisms were less common, though they tended to occur as secondary infections, but they interfered less with wound healing. Anaerobic infection was serious but less common. Diphtheritic infection occurred intermittently.

Blood transfusion, usually of two pints, was given, but in some cases of haemo-concentration serum was given instead. The general effect of the transfusion was held to be of definite value as very anaemic patients were thought to be very prone to develop the infection.

A report on three hundred cases of gas gangrene was submitted to the Rome conference in February 1945. It showed a mortality of 43 per cent. Gas was noted to be present in 93 per cent, and pain in 17 per cent of the cases. The organisms present were B. Welchii 66 per cent, Vibrio Septique 14 per cent, Malignant Oedema 9 per cent. B. Oedematiens was the most toxic organism and the least susceptible to penicillin. The report confirmed the opinion that surgery and penicillin were the only measures that were definitely of great benefit in treatment, but that blood transfusion was also valuable.

An opinion was expressed that the incidence of gas gangrene was similar to that experienced in the First World War, an opinion quite contrary to that held by our officers who had served in both wars. In our experience of the Second World War gas gangrene had been uncommon and very few cases of serious infection had been met with, apart from those associated with damage to the main arteries of the limb. And our deaths had been very few. Our opinion was very definitely that the problem had been a relatively unimportant one, quite different from the ever-present anxiety experienced in the First World War. Contrary opinion could only be held by one without personal experience of large numbers of wounded men in both wars.

Infection by the Pyocyaneus was often seen at a later stage in wound healing, and often following the clearing up of the gram-positive infection. This caused little or no general reaction or symptoms, but interfered with the proper healing of the wound. Five per cent acetic acid solution proved the most satisfactory method of eradication. Coli infections were sometimes seen, often associated with other organisms.

This produced very serious wound infection as well as generalised effects such as severe toxaemia or paralysis in some cases. Locally the wound showed a very unhealthy condition, with indolent, thick, grey sloughs, and there was serious delay in healing. Anti-diphtheritic serum in large doses was indicated and brought relief, but the wounds took a long time to heal. Cases were noted in Egypt at different times, but the most marked epidemic was in Italy at 1 NZ General Hospital in the winter of 1944, when several wounds were seriously affected. The outbreak coincided with an epidemic of faucial diphtheria in the civilian population.

It was realised in the early part of the war in North Africa that the frequent dressing of wounds, especially during the period of evacuation to the Base, led to an increase in wound infection, though the use of the closed plaster treatment for the major wounds, including the fractures, acted as a safeguard, as no dressings were changed in these cases for at least ten days.

At the first Surgical Congress in Cairo in February 1942 the danger of cross infection occurring during wound dressing was recognised, and recommendation was made to leave all wounds alone during transit, except when some definite indications for inspection, such as bleeding or infection, were present.

At the base hospitals the problem was recognised at the pre-Alamein period, and it was found that cross infection was very common in the wards, and that infection was spread both from other wounded cases and by the staff of the hospitals acting as carriers, especially from infective foci in the naso-pharynx. It was also demonstrated that infection could be easily spread by dust from the floors, and also from bedclothes, especially blankets.

This was countered at first by increased ward cleanliness, especially by the control of dust by doing ward dressing at times when there was least movement in the wards, and by insistence on all members of the staff wearing face masks during the dressing periods. Instruments were sterilised before each dressing, strict aseptic technique instituted, and extra staff employed. Gloves were provided for use when dressing the wounds. Later special dressing rooms were utilised, where as many as possible of the patients were taken from the wards to have their dressings performed; and the rooms were well equipped to ensure asepsis. It was realised that infection was inevitable in every open wound, and that each dressing constituted a serious danger. ' Every open wound sooner or later is an infected wound.' The only safeguard was the closure of the wound.

The type of fresh infection varied as one would expect, but streptococcal infection was common.

There were marked differences in the incidence of infection in wounds at different periods of the war, and in the different terrains in which the battles were fought.

In the desert campaigns in general infection was not severe and the smaller wounds generally healed without becoming infected, even when no operation of wound cleansing had been undertaken. This was particularly noticeable in the first Libyan campaign, when the facilities for forward surgery had not been developed.

In Greece and Crete infection was marked, especially in Crete, where wound treatment suffered from the disorganisation brought about by the retreat and the capture of most of the seriously wounded. Tetanus was noted for the first time, and a Maori died from it after evacuation to Greece. Gas gangrene was also seen.

During the second Libyan campaign there was more sepsis, though again it was remarked by Major Furkert of the Mobile Surgical Unit that ' the absence of highly pathogenic bacteria minimised the seriousness of delay in admitting the cases for operations, and few fulminating infections were seen '.

Infection, however, was much more marked in cases seen at the Base, due undoubtedly to the delay in primary operation, the lack of water and adequate diet, and the prolonged and rough evacuation.

There was less sepsis noted in the pre-Alamein and Alamein periods. The facilities for forward surgery had improved considerably, the surgeons were more experienced, the lines of evacuation much shortened, and patients could be sent back to the base hospitals by train, road, and air. Sulphonamides were being given regularly following wounding. The Tunisian campaign was fought under very satisfactory conditions, and little sepsis was seen except in cases where operations had been seriously delayed. At the Base, however, serious sepsis was still seen in fracture cases, and it was realised that sulphonamides at that stage were not of any avail and resort was made to older methods of treatment.

During the Italian campaign the incidence and severity of infection was more marked, and this added interest to the penicillin experiments in wound treatment carried out at Tripoli, which led to the introduction of penicillin as a substitute for the sulphonamides in the prevention of wound infection. The increased infection also led to the more thorough cleansing of the wound.

This increase in infection was, however, successfully countered by the steadily increased use of penicillin, and the introduction of the technique of delayed primary suture of wounds when the cases arrived at the base hospital at about the fourth day led to the marked diminution of infection and the satisfactory healing of the wound in about 90 per cent of the cases. The penicillin had prevented the development of infection by the common gram-positive organisms, especially the streptococcus, and the closure of the wound had prevented subsequent infection of the wound.

The only dressing in the ordinary wound after the primary operation took place in the operating theatre of the base hospital, where the dressings were removed prior to the suture of the wound and under full aseptic techniques.

This was attempted during the First World War and met with some success in the latter part of the war under certain ideal conditions. Under ordinary conditions of warfare in France, however, it was not successful, and the routine treatment was to leave the wound open, counteracting infection by the Carrel-Dakin method until the wound was fit for secondary suture at the Base.

During the Second World War, in the early period in North Africa, primary suture was carried out on abdominal and head wounds, usually with the introduction of temporary drains. Face wounds were at first sutured in the forward areas, but later any large wound was left to be sutured at a facio-maxillary centre at Base, as primary suture had often produced unsatisfactory cosmetic results. During the second Libyan campaign amputations carried out at the sites of election were primarily sutured by some of the forward surgeons, especially in Tobruk, but the results at Base were found to be unsatisfactory and the practice was discontinued. Suture of sucking chest wounds was also performed as a primary operation, but gave place to delayed primary suture for skin, although muscle suture was carried out at the primary operation. Primary suture of wounds of the scrotum was often undertaken to protect the testes and to prevent contamination.

Generally, however, primary suture was discouraged, as under war conditions it proved unsatisfactory. Late in the war in northern Italy success attended an experiment in which lesser wounds were referred to a CCS for primary suture during a quiet period when the patients could be held until the wounds were healed, with a resultant saving of much time in convalescence. In the future it should be possible to undertake primary suture in a large proportion of uncomplicated wounds when casualties can be rapidly evacuated to hospitals, where the patients can be held, and where there are sufficient surgeons to attend to the minor, as well as the serious, wounds. Careful wound cleansing, together with administration of antibiotics from the earliest opportunity after wounding, and the provision of rest to the injured area should ensure that primary suture will be successful.

During the First World War the French reported successful suture on the fourth day after wounding. The use of the closed plaster technique precluded early suture at the beginning of the Second World War. The penicillin trials in Tripoli proved that in many cases wound suture could be successfully carried out within a few days of wounding with the help of penicillin.

In Italy careful wound toilet in the forward areas, and the application of penicillin powder in a base of sulphanilamide to the wound surface, enabled the wound to be successfully sutured on the fourth or fifth day at the base hospital when the original splint and dressing were removed. Later when penicillin became available in ample quantity it was administered parenterally from the earliest opportunity after wounding until delayed primary suture was undertaken, and generally for several days afterwards. This ensured success in the great majority of cases and greatly improved the results in fracture cases. The early healing of the wound prevented secondary infection with its associated serious illness, and greatly shortened the period of hospitalisation and convalescence. It was proved conclusively that with adequate primary surgery, under suitable conditions, and with the use of penicillin, early wound suture was not only practicable but also highly successful.

Suture of a wound after the first week or ten days has been described as secondary suture. This was the routine procedure at the end of the First World War, when the Carrel-Dakin treatment was used to render the large wounds fit for suture. The operative technique often entailed the removal of the granulating area of the wound, the freshening of the skin edges, and the freeing of tissue layers, which could then be brought together separately by figure-of-eight silk skin sutures.

A relatively small number of cases were dealt with by secondary suture in the Second World War. This was due to the use of the closed plaster technique under which the wound was allowed to heal slowly without suture, and also to the early evacuation of the heavy cases to New Zealand. In the latter part of the war the success of delayed primary suture rendered secondary suture unnecessary in most cases, but it was performed on a few cases after their treatment in saline baths or by the hypochlorites or other antiseptics.

This was carried out by the plastic surgeons in certain large wounds which could not be sutured, and in which it was important to obtain a covering of solid skin. This particularly concerned fracture cases with bare bone exposed in the wound, injured areas on the flexor aspects of the elbow and knee where tissue contraction was to be feared, and areas on which pressure was exerted such as knee, elbow, and heel. Sliding and pedicle grafts were used.

This was more commonly adopted as the war progressed. The techniques were developed especially to deal with the raw areas so common in burns cases, but were frequently used for the healing of gunshot wounds. Early grafting was done in special areas such as the face and fingers, but on the large wounds grafting was at first performed at a comparatively late stage to bring about skin cover when suturing was impossible. When delayed primary suture became established as the routine method of treatment for wounds, skin grafting was carried out at the same time (on the fourth day) to cover any raw areas which could not be dealt with by suture.

Our Division was not involved in this campaign, but our Medical Corps had the privilege of treating a considerable number of Australian and other casualties in the Helwan hospital. The wound treatment carried out was the surgical ébridement of the wound, followed by the closed plaster treatment. It was noted that there was little serious infection and that the smaller perforating and penetrating wounds generally healed satisfactorily.

The majority of the larger wounds also showed little serious infection, though the treatment was prolonged and necessitated much changing of plaster splints. Pyocyaneus infection was common and many of the wounds sluggish in healing in consequence. The smell of the stained plasters was objectionable and was aggravated by the heat of Egypt.

Comparatively little wound treatment was carried out by our units in Greece, except simple primary treatment in the forward areas by the RMOs and the Field Ambulances. Some surgical treatment was possible, however, at the Thermopylae line, where the closed plaster technique was used and sulphonamides given orally to serious cases.

In Crete more surgical work was done by our Field Ambulances and by our surgical team attached to British units, though the conditions and some lack of supplies made adequate treatment extremely difficult. Infection was marked in many cases and drainage was much utilised. Nearly all seriously wounded men became prisoners of war and were later evacuated to Greece by the Germans. One case of tetanus occurred in our force and the patient died at Athens, and gas gangrene was also seen.

In this campaign our Division experienced serious casualties. The majority of the wounded were captured by the enemy while they were in the main dressing stations and were not relieved for ten days. During this time they suffered from serious lack of water and also from restricted rations.

Wound treatment had to be undertaken often at the ADS when out of contact with the MDS. Excision of wounds, drainage of infected wounds, and removal of obvious foreign bodies was carried out at one ADS in addition to the control of bleeding, the amputation of shattered limbs, and the suture of sucking chests. Acriflavine was used for the primary dressing. It was noted that the majority of deaths were associated with severe loss of blood. The main wound treatment was undertaken by our Field Ambulance MDSs, and also by the very well equipped and staffed Sims Mobile Surgical Unit. All types of cases were operated on by this unit, including abdomens, chests, and heads, but lack of water during the period of captivity rendered sterilisation difficult and the provision of sterile gowns and towels wellnigh impossible. Still more serious was the severe lack of drinking water and fluid for transfusion, which made it impossible to counteract the marked dehydration present in all cases, and particularly in the abdominal cases. Major Furkert, OC Mobile Surgical Unit, reported that ' By this time the water and food situation was desperate and patients began to die rapidly from dehydration.'

Furkert wrote a very clear account of the conditions of the wounded in this campaign and their treatment. He stated that hardly any of the casualties reached the unit within twenty-four hours of injury and many wounds were over three days old. The absence of highly pathogenic bacteria minimised the seriousness of this delay and few fulminating infections were seen, though severe infection was noted in many cases. There were serious deficiencies in supplies of all kinds—particularly ether, morphia, and plaster-of-paris. The shortage of water was desperate, and no patient was washed in any way for eleven days. Wound treatment consisted of excision with gauze lightly packed in the wound and plaster splints.

Observation of cases at the Base in Egypt showed that sulphanilamide powder was almost a universal wound treatment and that gauze dressings were used. Plaster was extensively used in the treatment of severe wounds, and fractures of the leg and forearm were universally treated in enclosed plasters. The fractured femurs were treated in Thomas splints, and cases from Tobruk were in the Tobruk splint, a combination of plaster and Thomas splint. Fractured humerus cases were mostly treated by posterior slab splints and simple slings, sometimes by Kramer wire splints and at times in abduction plasters. Severe sepsis was present in many wounds, and secondary haemorrhage and amputations were relatively common in the base hospitals. Gas gangrene, however, was infrequent. The conditions of the campaign had prevented adequate wound treatment and especially early and rapid evacuation. Sepsis had in consequence been marked in contrast to that seen in the first Libyan campaign, and this stressed the importance of early and adequate forward surgery. No gas gangrene was seen in our New Zealand base hospitals. The gangrene seen was in every case due to damage of the main vessels of the limb.

The saline bath treatment, as introduced for burns, was adopted for the treatment of chronic infections in limb wounds, in conjunction with both local and general sulphonamides. An elaborate bath unit, the only one in the Middle East, had been installed at our Helwan hospital, where there was a plastic surgeon.

At a conference held in Cairo in February 1942 in the quiet period following the second Libyan campaign, there was agreement on the value of the surgical cleansing of the wound of all devitalised tissue and on the importance of the removal of devitalised muscle.

The necessity of adequate incision to permit both proper inspection of the wound and subsequent drainage was recognised. Small perforating wounds had in the great majority of cases healed satisfactorily without any surgical treatment.

Dressings had consisted of vaselined gauze laid loosely in the wound. The poor results of plugging wounds with gauze were commented upon. The immobilisation of limb wounds in plaster without further dressing of the wound for ten days was the normal line of treatment, but later dressings of hypochlorite and other antiseptics were being utilised in conjunction with the plaster splinting. The Pyocyaneus infection, so often an aftermath of the closed plaster treatment, proved difficult to eradicate, and acetic acid was being used in its treatment.

The lessons learned from the second Libyan campaign had borne fruit. There were better facilities for surgery, and more experienced surgeons were available. The lines of evacuation for the casualties were considerably shorter. Much less sepsis was seen in the wounds, this being due, it was stated, to earlier operative treatment and more efficient local sulphonamide therapy, especially to the wound. The sulphanilamide sprinklers had been issued to all field units, and sulphonamide tablets were given regularly. Closed plaster technique was still utilised and the splinting of fractures had improved, especially with regard to fracture of the femur. Our New Zealand technique of a combination of Thomas splint and plaster bandaging, a modification of the Tobruk method, had been introduced with great success. The utilisation of a plaster table for the application of spicas and shoulder casts was discussed, as difficulty in applying such casts was being met with, especially as plaster spicas were being utilised for large buttock wounds.

The plaster spica proved unsatisfactory when long evacuation was necessary, especially over the rough surface of the desert. Pressure sores were almost inevitable under those conditions unless very careful padding was carried out. No other splintage, however, was available for the hip and buttock cases.

The surgical set-up for the Alamein battle had been arranged carefully beforehand, with the result that there was a satisfactory distribution of the operative work and more efficient evacuation, which was, of course, facilitated by the close proximity of the front line to Alexandria.

The normal wound treatment had become stabilised at this time. Surgical cleansing of the wound was understood by all the operating surgeons. Sulphanilamide powder was sprinkled on the wound as a fine dust. Vaseline gauze or tulle gras dressings were applied without plugging, and the limb put up in an enclosed plaster. Sulphonamide tablets were given regularly, and dosage cards affixed to the field medical cards. Blood was available in ample quantity, even up to the RAP, and was liberally given. Field transfusion units were attached to the operating units.

An order had been issued some time prior to the battle that all plasters must be split, but the order was not always carried out, and extra work was given to our CCS in splitting the overtight plaster splints and some limbs saved by the relief of tension. Fracture cases were efficiently splinted, mostly in plaster, the femur being splinted in the standardised New Zealand method.

During this period our New Zealand medical services had exceptional facilities both to observe and perform forward surgery. Our CCS was privileged to be the most forward CCS during the whole campaign, and had attached to it British specialist personnel of excellent ability as special neurosurgical, ophthalmic, field surgical and transfusion units. Probably 50 per cent of all casualties passed through our CCS during the campaign. Our Field Ambulances were also very active, well equipped, and very well staffed, and they carried out a great deal of major forward surgery. At one stage in the campaign some casualties were first seen a considerable time after being wounded. The wounds were generally very septic, even small penetrating wounds without any serious muscle damage. This tended to show that our lack of sepsis was definitely due to the surgical treatment, and not, as happened in the first Libyan campaign, due to a real absence of primary infection. Blood-transfusion arrangements were now functioning perfectly, and two to three pints were given to the individual case when required. Wet serum was also available and was often given to supplement the whole blood.

It was noted at this period that there was very little sepsis in our New Zealand cases at the base hospitals, and only a very few septic fracture cases, and little or no sepsis in the knee-joint cases. The head, chest, and abdominal cases had done very well, and secondary haemorrhage and late amputation had been very uncommon, a sure sign of absence of infection. Skin grafting was being commonly carried out, and very large flesh wounds complicating infected compound fractures were successfully grafted, with great improvement in the general condition of the patient, as well as more rapid return of local function.

The wound treatment at that time consisted of cleansing the skin of the limb with plain soap and water, and with shaving, not only for cleanliness, but preparatory to the application of elastoplast for extension. Iodine was then applied to the skin. The removal of skin had been restricted to the minimum, only definitely damaged devascularised edges being excised. The same applied to all the wounded area. Muscular excision was carefully carried out so that all avascular and badly traumatised muscle was removed. Only definitely loose fragments of bone were ever removed. Free, and if possible dependent, drainage was provided in all large wounds associated with much muscle or bone damage.

Generally the nerves were not dealt with, but were closely inspected to ascertain whether they were damaged or not, and clear notes written for the information of surgeons at the Base. Sometimes divided ends were sutured to facilitate operative repair later.

The treatment of wounds of the joints was conservative, it having been found that small perforating and penetrating wounds of the joints did not cause trouble if adequate splintage was applied. For large wounds the practice was adequate excision and, if possible, removal of large foreign bodies, and again adequate splinting by means of plaster.

Delayed primary suture became the routine treatment of all cases deemed suitable for suturing, whether simple wounds or those complicated by fracture-not always with perfect success, but never with any disastrous infection supervening. At times penicillin was not available at the base hospital, and in its absence suture was still carried out with success.

The wounds were arriving at 2 NZ General Hospital at Caserta early in 1944 in such excellent condition that suture was done in practically all cases on arrival, and there were very few patients with unhealed wounds sent on to 3 NZ General Hospital at Bari, except the fractured femurs purposely sent there without treatment at Caserta.

Fractures of the upper extremity were also routinely sutured at our hospital at Caserta; the leg fractures, causing difficulty because of the tension of the wound, were only occasionally sutured.

The most difficult wounds were those involving the hip joint, where sepsis was difficult to combat without the ability to give large doses of intramuscular penicillin.

In May 1944 a clinical meeting was held behind the Cassino front at 1 British CCS and forward surgery discussed. The progress in wound treatment was illustrated by the treatment of a case of severe trauma of the scapula, and scapular muscles, with anaerobic infection, which cleared up well after the primary operation, with the aid of parenteral penicillin, and delayed primary suture was carried out with success. The necessity to perform early amputation in the case of shattered limbs was being appreciated more and more, and recommendations were made for this to be done as a first priority, along with the control of severe bleeding. In mangled limbs, if amputation could not be immediately carried out, the application of a tourniquet just above the damaged area prevented further bleeding and the often serious deterioration seen in these cases, possibly due to toxic absorption. The dramatic improvement often produced in a patient's condition immediately a mangled limb was removed was vouched for by many experienced surgeons. This was in some ways comparable to the improvement in gas gangrene cases brought about by the efficient removal of the affected muscle groups. The amputation in these cases had to be done through healthy tissue above the devitalised area, as it was in the amputations through the injured area that our worst septic cases had arisen.

Flap amputation was the rule, and delayed primary suture was generally quite satisfactory. At the primary amputation only sufficient stitches to prevent retraction were allowable, and any packing had not to be tight. Badly injured feet generally required amputation, but with early penicillin treatment, and the prevention of sepsis, more were now saved. It was then noted that the results of wound treatment were so much better that the level of amputation could be reconsidered. Amputation, especially in the lower leg, could with benefit be performed at a level which would render re-amputation unnecessary.

Knee joints even with retained foreign bodies were doing well with intrasynovial penicillin and adequate splintage. Infected cases still required drainage occasionally and, unfortunately, amputations were still at times necessary.

During the advance to Florence an adjustment of the treatment of the wounded was made by the alteration of priorities. Ordinary wounds, either with or without fracture, were dealt with at the MDS, and the heavier cases, including the abdominal and chest cases, if fit to travel, were sent back to the CCS. (The head, jaw, and eye cases were sent still further back to a British CCS, to which special centres were attached.) The alteration in attitude was brought about by the realisation that, in the case of the abdominals, recovery from shock was essential before operation was carried out, and that urgent operation was unnecessary, and indeed undesirable. The concentration on the flesh wounds at the MDS at an early stage ensured the wounds being in a satisfactory condition for the performance of delayed primary suture when the cases reached the General Hospital.

As reported at the Rome conference, the majority of the fracture cases had been sutured with success, but about 20 per cent were thought to be unsuitable for suture. The plating of compound fractures had not, on the whole, been satisfactory, and a more conservative view was being adopted in this regard by the surgeons who had carried out experiments in this form of treatment.

The Consultant Surgeon 2 NZEF had for some time counselled against the removal of bone in fracture cases, especially large pieces, and in the humerus where non-union was so prone to occur. This view was supported at the conference by one of the younger surgeons, and this support established this line of treatment in our units. The utilisation of bone chips in the repair of bony defects of the jaw, and of the skull, seemed to make the removal of clean bone from a clean wound an absurdity, and as the very large majority of our fracture cases were progressing well on a straightforward course of primary wound treatment, followed by delayed primary suture, we considered no bone, loose or not, should be removed, and we had no cause to regret our changed procedure.

At the time of the Po battle the working MDS carried out some of the minor surgery, while the CCS did the abdomens and chests and the major urgent surgery. No. 1 NZ General Hospital in Northern Italy did some primary surgery and the bulk of the delayed primary suture of the wounds. No. 3 NZ General Hospital in Southern Italy dealt with some primary surgery and some delayed primary suture of wounds, and a large proportion of the heavier cases had been sent direct by air from the CCS for base hospital treatment. The marked improvement in the surgical technique in the treatment of war wounds had enabled this to be done.

In April 1945 the Consultant Surgeon 2 NZEF wrote:

We can comment that the treatment of war casualties at the end of the European war has reached a very high level of efficiency, both in the saving of life, and particularly in the freedom from sepsis, and in the rapid repair of wounds. To this progress, the NZ Medical Corps has contributed its share and has rapidly adopted any progressive developments in treatment. Our young medical officers in the forward areas have especially distinguished themselves by their painstaking and skilled work.

A table reproduced at the end of this chapter shows the types of wounds which led to invaliding from base hospitals to New Zealand, and compares the figures for 1 NZEF in France with those for 2 NZEF.

The forward surgery for 3 NZ Division in the Pacific was carried out by field surgical units attached to Field Ambulances and by the Field Ambulances themselves, but it was limited as there were few casualties in the division in the island assaults from October 1943 to February 1944. Lieutenant-Colonel S. L. Wilson, a forward surgeon with 2 NZ Division, was transferred to the Pacific, and wrote a short directive on war surgery which was circulated to all medical officers.

The wound treatment consisted of surgical cleansing, light packing and dressing with vaseline gauze or tulle gras, while plaster splints were used for fractures and large wounds following the Trueta technique. Primary operation was often much delayed by the difficulties of evacuation from the jungle. Sulphonamides were used both locally and by mouth. Penicillin was only available in small quantity at the end of the campaign. Infection was not marked, but some anaerobic infection with gas gangrene was seen. Secondary suture was carried out at the CCS in some cases. There were no special difficulties encountered in wound healing.

The position as regards the treatment of war wounds at the end of the war may be summarised as follows:

The technique of surgical cleansing

The words ‘surgical cleansing’ have been deliberately chosen because of the obscurity of meaning attached to the name excision, and, to a lesser extent, to the French word ébridement.

Wounds in Action 2 NZEF 1940–45

2 NZEF (IP) not included.

1 NZEF May 1916– Dec 1918 Head 276 440 Eye 216 172 Chest 297 616 Abdomen 202 268 Amputations, leg 307 195 Amputations, arm 80 159 Spine 53 91 Nerve lesions 622 Knee joint 85 Shoulder joint 45 Burns 24 Vascular 55 Fractured feet 245 Fractured jaw 86 Fractured femur 346 Fractured tibia and fibula 481 Fractured humerus 350 Fractured forearm 360 Ear 120 Pelvis and hip 100 Other 259 364 Other wounds of back 174 Perineum 50 Other wounds of arm 2300 Other wounds of leg 2683 Multiple wounds 79 —— —— TOTAL 4609 7591 Total wounded for period 16,456 36,516 Also wounded taken PW 1,326